Single-Incision Laparoscopic Choleystectomy (SIL-C) Using a Novel Technique for Retraction of the Gallbladder: Evaluation of the Initial Experience

Carlos A Galvani, MD, Rakesh Hegde, MD, Angela Echeverria, MD, Tim Rankin, MD, Behrooz Dehdashti, PhD. Section of Minimally Invasive Surgery, University of Arizona, Department of Surgery

Objectives: SIL-C is evolving as an improved technique and an alternative to NOTES. The impossibility to use assistants impairs the the adequate retraction of gallbladder fundus. We have developed a novel self-retaining internal retractor to overcome this challenge of gallbladder retraction.
Description of the technology and methods: A single port platform was used for access in every patient. The self-retaining internal retractor was developed by attaching a Lone Star stay hook (Lone Star Medical products, Stafford, TX) to the back of a laparoscopic bulldog clamp. (Aesculap, Tuttlingen, Germany) To retract the gallbladder, the internal retractor was introduced through a 12mm trocar, which was inserted through a single port and deployed at the gallbladder fundus using a laparoscopic bulldog applicator. Then, using a laparoscopic needle driver the hook needle was grasped and attached to the parietal peritoneum of the right hemidiaphragm, thereby enabling cephalad retraction of the gallbladder. The internal retractor was repositioned as needed. To carry out dissection, one straight bariatric –length instrument and a flexible –tip “L” hook cautery were used.
Preliminary Results: Between July 2010 and January 2011, 10 patients underwent SIL-C. There were 9 female patients. Mean age and BMI were 42+13 years and 27+ 5 kg/m 2. Preoperative diagnosis in 8 patients was cholelithiasis one patient had gallbladder polyp another patient was acalculous cholecystitis. Two patients had previously undergone gastric bypass for morbid obesity. In all the patients we used the internal retractor for the retraction of the gallbladder fundus. One patient underwent robot-assisted SIL-C. Average operative time was 53+20 minutes; average blood loss was 7+5 ml. No conversion to open surgery or conventional laparoscopy was observed. Postoperative pain assessed at discharge using facial expression scale at 4 hours after surgery was of 2. There were no intraoperative or postoperative complications.
Conclusions/Future directions:
The self-retaining retractor allows the surgeon to perform the cholecystectomy without additional instruments or assistance. In this initial experience, the internal retractor has shown to be adaptable, reliable, safe and easy to use. Advantages are that this new device is versatile, reusable, reduces the numbers of incisions, and is re-adjustable. In addition, more retractors can be added if necessary. The new design will have a better grip than the bulldogs on tissue to be retracted thereby improving retraction. Also a new silicone ring with a needle will replace the Lone Star stay hook. This new silicone ring will be easier to attach to the clamp.
The adaptability of the novel device will give the surgeon the freedom to perform more complex maneuvers, which will broaden the range of procedures surgeons can perform through a single-incision.